AIRCRAFT ACCIDENTS and INCIDENTS for... · the whole of the investigation into a major aircraft accident involving a ATR 72-500 aircraft at Port Vila, Vanuatu, in accordance with

AIRCRAFT

ACCIDENTS

and

INCIDENTS

GUIDANCE

for

AIRCRAFT OPERATORS

and

SERVICE PROVIDERS

GENERAL ENQUIRIES

PNG Accident Investigation Commission

Level 1, NAQIA Haus, Portion 81, Moera Tobo Rd, 6 Mile, National Capital District, PNG

PO Box 1709, BOROKO, National Capital District, PNG

Tel: +675 323 2911,

Fax: +675 323 2139,

E-mail: [email protected]

Website: www.aic.gov.pg

TO REPORT AN AIRCRAFT ACCIDENT or INCIDENT

Telephone the

Civil Aviation Safety Authority of PNG (CASA)

+675 302 7528 (21:30 – 06:00 UTC) +675 7698 0239 (06:00 – 21:30 UTC) +675 7031 4167 (06:00 – 21:30 UTC)

and the

PNG Accident Investigation Commission (AIC)

+675 323 2911 or +675 7550 0715 (06:06 - 21:45 UTC) Duty Investigator +675 323 2184 or +675 7550 0703 (06:06 - 21:45 UTC) Duty Investigator

mailto:[email protected]

http://www.aic.gov.pg/

Aircraft Accidents and Incidents Guidance for Aircraft Operators and Service Providers

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Contents

Statement by the Minister for Civil Aviation 2

Foreword by the Chief Commissioner 3

1. About the Accident Investigation Commission 4

2. What is an accident or serious incident? 7

3. Who should report the accident or serious incident and how? 8

4. What the AIC needs to know — Notification 9

5. Preservation of evidence 10

6. The role of the AIC 11

7. The AIC’s legal powers to investigate 12

8. Legal powers of an AIC Investigator 13

9. The AIC response 13

10. The investigation process 15

11. Safety Recommendations 16

12. Safety actions 16

13. Areas not within the scope of the investigation 16

14. International context 17

15. Participation in AIC investigations 17

16. Overseas investigations 17

17. The role of the Advisor 18

18. Operator emergency planning 19

19. AIC interface with an operator or service provider during an investigation 20

20. Internal investigations conducted by operators and service providers 21

21. Media relations 22

22. Passenger assistance 23

23. Flight Data and Cockpit Voice Recorders 24

24. Police and judicial investigations 27

25. Civil Aviation Regulator 28

26. Accident site safety 28

27. Recovery of wreckage 29

28. Wreckage recovery from the sea 30

Appendix A: Extracts from ICAO Annex 13 to the Convention on International Civil Aviation 33

Appendix B: Roles of the investigation team members 36

Appendix C: AIC_F018 Formal Request for Interview or Production of Evidence 37

Appendix D: AIC_F044 Declaration of Conflict of Interest 39


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Statement by the Minister for Civil Aviation

As Minister responsible for Civil Aviation I am pleased to provide a statement of endorsement to this Booklet produced by the PNG Accident Investigation Commission, providing as the title states GUIDANCE FOR AIRCRAFT OPERATORS AND SERVICE PROVIDERS.

The AIC is the Nation’s lead agency in conducting independent no-blame aircraft accident investigations to determine why an accident or serious incident happened and make findings and recommendations for preventing similar accidents in the future. It is independent of all regulatory and judicial authorities, and service providers

The expectations of the International Civil Aviation Organization are being met and in many areas are being exceeded by the AIC. ICAO expects completion of investigations with the public release of reports within 12 months, so I am particularly pleased that the AIC is producing high quality investigation reports that are receiving endorsement from ICAO, States of Manufacture, and aircraft manufacturers well inside the ICAO time guidelines. Significant safety actions have been taken by aircraft manufacturers, operators and service providers to address safety concerns identified during AIC investigations, with some having international ramifications for global aviation safety.

The AIC is now well placed as a leader in aircraft accident and serious incident investigations in the South Pacific Region. This International recognition of the AIC’s investigation capability was evidenced on 28 July 2018 when the Government of the Republic of Vanuatu requested assistance from the AIC and subsequently delegated the whole of the investigation into a major aircraft accident involving a ATR 72-500 aircraft at Port Vila, Vanuatu, in accordance with ICAO Annex 13 Standards.

The Chief Commissioner, Mr. Hubert Namani, and his executive management team have shown strong leadership and the strength of commitment of the AIC team of investigators and support staff is obvious to me, and I congratulate all members of the AIC for the service they are performing on behalf of the Nation.

On 26 January 2018 I officially opened the Commission’s new office at 6 mile, National Capital District. The new office with its technical resources including a Flight Recorder Laboratory, brought the AIC a major step closer to ensuring the AIC will be able to keep pace with technological advancements in the aviation industry.

I am committed to ensuring the AIC is able to meet its International obligations and its legislated mandate, through appropriate resourcing.

I commend this guidance booklet to all PNG aviation industry personnel. Hon. Alfred Manase, MP

Minister for Civil Aviation

23 September 2018


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Foreword by the Chief Commissioner

Aircraft operations within PNG and those operated to and from PNG by International airlines have a high safety record. The rate of aircraft accidents and serious incidents in PNG in recent years has reduced and with that reduction, the rate of fatal accidents has reduced. This improvement cannot be taken for granted. On occasions, an aircraft, its crew and passengers may be involved in an occurrence requiring investigation by the PNG Accident Investigation Commission (AIC). There may also be occurrences involving providers of aviation services and infrastructure. These occurrences are classified as accidents or incidents.

All safety occurrences, accidents, serious incidents and incidents must be notified to the Civil Aviation Safety Authority, with the requirement to notify accidents and serious incidents with a minimum of delay and by the most suitable and quickest means available. The Civil Aviation Rules require an initial notification to be followed within 3 days by a written notification report to CASA using the Form CA005.

Operators may choose to conduct an internal initial investigation, but that must not delay the notification to the Authority without delay immediately following the occurrence, in order to ensure that perishable evidence such as recorded flight data is secured. The initial notification should also be made to the PNG AIC. The AIC is the authority for investigating accidents and serious incidents occurring in PNG and its territorial waters.

The AIC, while having a legislated mandate to investigate accidents and incidents, will assess the reported occurrence and normally will investigate accidents and serious incidents, deferring to CASA to investigate the incidents if CASA deems such investigation appropriate and necessary. The AIC complies with the Standards of ICAO Annex 13 in investigating occurrences and publishing findings, safety action, and safety recommendations.

Modern technology has enabled the AIC in most cases to download Flight and Voice recorded data from an aircraft without having to take the Flight Recorders to the laboratory. This is termed “on-wing download”. This greatly assists aircraft operators in minimising aircraft down time.

Although the investigation into accidents and serious incidents is conducted by PNG’s independent no-blame investigation authority, the AIC, aircraft operators and service providers have an important part to play in the investigation process. The AIC involves them as well as investigation authorities in the States of Registration, Operator, and Manufacture as well as manufacturers throughout the investigation process.

This booklet, prepared by the AIC, sets out what the AIC will normally do, what the AIC expects of an aircraft operator and service providers and how the AIC will interface with an operator and/or service provider during an investigation. It has been developed not only to inform PNG-based operators and service providers, but also foreign airlines operating aircraft to and from PNG.

Hubert Namani, LLB

Chief Commissioner

23 September 2018


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1. About the Accident Investigation Commission

AIC objective

Safe transport

Our mission The AIC’s mission is to improve aviation safety by conducting no-blame safety

investigations to establish the causes and contributing factors of accidents and

serious incidents, and to communicate the findings and recommendations

through public dissemination of the reports in compliance with the PNG Civil

Aviation Act 2000 (as amended) (CAAct) and the Standards of Annex 13 to the

Convention on International Civil Aviation.

Mandate and primary function In accordance with Part XIII of the CAAct, the AIC’s primary function is to improve

aviation safety by investigating accidents and serious incidents, determining the

factors that affect, or may affect, aviation safety, and communicating its findings

to relevant stakeholders. The AIC conducts its investigations on a ‘no-blame’

basis. This means the AIC does not apportion blame or liability and does not seek

to determine any liability of persons or organisations in transport matters.

Investigations that focus on future safety rather than blame increase stakeholder

awareness of, and action on, safety issues and foster industry and public

confidence in the transport system. Publishing reports which explain how and

why accidents and serious incidents occurred increases safety awareness and

knowledge and forms the basis for stakeholders to improve safety action.

Annex 13, to the Convention on International Civil Aviation, and the International

Civil Aviation Organization (ICAO) documents and circulars relevant to aircraft

accident and serious incident investigation set out the standards and procedures

against which the AIC benchmarks its work.

Independence Section 248 of the CAAct provides the basis for the AIC’s powers of investigation,

and its independence and primacy over evidence.

Section 8 states that the principal functions of the Minister under the CAAct

includes that he will ensure that Papua New Guinea’s obligations under

international civil aviation agreements are implemented.


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Therefore, the AIC must comply with the Standards of ICAO Annex 13,

specifically:

Section 3.1: A State shall establish an accident investigation authority that is

independent from State aviation authorities and other entities that could interfere

with the conduct or objectivity of an investigation.

Section 5.4: The accident investigation authority shall have independence in the

conduct of the investigation and have unrestricted authority over its conduct,

consistent with the provisions of this Annex.

Section 5.4.1: Any investigation conducted in accordance with the provisions of

this Annex shall be separate from any judicial or administrative proceedings to

apportion blame or liability.

Independent, objective, no-blame investigation of aviation accidents and serious

incidents by a capable PNG safety investigation agency makes a significant

contribution to domestic aviation safety and in some circumstances will

contribute to aviation safety globally.

Our strategy

We pursue our Mission by:

• focusing on occurrences, unsafe situations and data where the greatest safety

benefit can be gained within our given budget through timely investigation, safety analysis and research;

• better matching the delivery of our outputs to the needs of our stakeholders

and maximising safety education, including through the use of the Internet;

and

• working within, and helping to develop independent transport safety

legislation, regulations and/or rules and guidance material to ensure we meet our constitutional role and international obligations.

The organisation

The AIC is led by a Chief Executive Officer who has functional responsibility and

strategic oversight of the AIC, reporting to the Chief Commissioner and the Board

of the Commission.

The AIC is responsible for investigating accidents and serious incidents involving

civil aircraft operations in PNG, and assisting other States investigating an

occurrence involving a PNG registered aircraft overseas.

The AIC’s headquarters, which includes a Flight Recorder Laboratory, is located

in Port Moresby on Level 1, NAQIA Haus, 6-Mile. The AIC consists of about 15

employees located at the AIC’s headquarters in Port Moresby.


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AIC Office Port Moresby

The executive management team, is comprised of a CEO who is responsible for

strategic planning and leadership of the AIC, a Manager of Finance and

Administration, and an Investigations Manager responsible for investigation

operations.

The Board comprised of three Members, including the Chairman/Chief

Commissioner, reviews the facts contained in AIC investigation reports, makes

findings and recommendations as to the contributing factors and causes of an

accident or incident following recommendation of the Final Report by the

Investigations Manager and the Chief Executive Officer (CEO). The Chief

Commissioner approves the publication of all Investigation Reports and Safety

Recommendations.

Investigators (See Appendix B) cover the broad aviation disciplines of Flight

Operations, Air Traffic Control and Airports, Aircraft Maintenance Engineering,

and Flight Recorder Engineering. Administrative support is provided by an

Investigation Support Officer, Accountant, Legal Officer, IT Officer, and

Property/Assets Officer.


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2. What is an accident or serious incident?

The definitions of an aircraft accident and serious incident are contained in the

PNG Civil Aviation Act 2000 (as amended), Civil Aviation Rules Part 12, and ICAO

Annex 131 The relevant extracts are shown in Appendix A.

The definition of an accident includes:

An aircraft accident is an occurrence associated with operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as

all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time as it comes to rest at the end of the flight and the primary propulsion system is shut down, in which the aircraft incurs damage (with certain exceptions) or any person suffers death or serious injury.

Examples:

● A Britten Norman Islander was destroyed during controlled flight into terrain at an altitude of 9,500 ft. The sole occupant, the pilot, was fatally injured. This was an accident.

● A Bell 407 helicopter took off with the pilot unaware that a sling load of fuel drums was attached. The take-off profile used was not for such a load and the load dragged and the helicopter impacted the aerodrome apron.

The helicopter was substantially damaged, but the occupants were uninjured. This was an accident.

● An ATR 42 freighter over-ran the departure end of the runway during a rejected take-off and was destroyed by impact forces and post-impact fire. This was an accident.

The definition of an accident is clear. However, serious incidents appear to be

less understood.

A serious incident2 is defined in ICAO Annex 13 as:

‘an incident involving circumstances indicating that there was a high

probability of an accident....’.

All incidents must be reported to CASA and desirably the AIC in the same way

and with the same time importance as accidents.

1 Annex 13 to the Convention on International Civil Aviation. 2 See Appendix A


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If any doubt exists, the incident should be reported and the AIC will make

the determination if it constitutes a serious incident.

Examples:

● A Dash 8 and a Kodiak 100 were on opposite direction reciprocal tracks when the Dash 8 was cleared to descend and the Kodiak was cleared to climb. The aircraft were in such close proximity that at the closing speed of 321 kts they were 5.6 secs apart when the Kodiak pilot took

evasive manoeuvring action. This was a serious incident.

● A Casa 235M aircraft landed on a runway that was closed for runway works with men an equipment on the runway. The closure had been the subject of a NOTAM for 12 months prior to the landing. This was a serious incident.

● A Fokker F70 was cleared to take off and turn right. It turned into the path of an arriving Kodiak 100 and received a TCAS RA. This was a serious incident.

● Emergency release of sling load from a Bell 407 that entered a high rate of sink at 11,000 ft. This was a serious incident.

3. Who should report the accident or serious incident and how?

It is a legal requirement that when an accident or incident occurs in or over

PNG, or occurs elsewhere to an aircraft registered in PNG, the pilot in command

of the aircraft involved at the time of the accident or incident, or if he has been

killed or is incapacitated, the operator of the aircraft, is required to notify CASA

with a minimum of delay and by the most suitable and quickest means

available.

In the case of an en-route TCAS RA the pilot in

command is still required to make the notification with

a minimum of delay and by the most suitable and

quickest means available. That may be by reporting the

TCAS RA to ATC or to the aircraft operator using the

company radio frequency. In all such cases, the

responsibility then rests with the ATC or the operator

to notify CASA with a minimum of delay and by the most

suitable and quickest means available and desirably also notify the AIC.

This applies irrespective of the country in which the operator is based, the

country of registry of the aircraft or the country of domicile of the flight crew.

It is an obligation on all people involved in aircraft operations or aviation services

to notify CASA of incidents and accidents, in particular if the incident is a serious

incident or hazard to the safety of aircraft operations.


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Civil Aviation Rule Part 12.55 (b) is clear that this includes any person involved in

such incidents if that person operates, maintains, services, or does any other act

in respect of any aircraft, aeronautical product, or aviation related service, even

if not employed by or associated with the aircraft operator.

The AIC’s 24/7 accident notification phone numbers are:

The AIC accident and serious incident Duty Investigator is contactable 24 hours a day, 7 days a week. Aircraft operators and Service Providers should ensure that this number is easily accessible to all staff who might need to report an incident or accident and that it is included in the operator’s emergency planning documents.

Note: The above telephone numbers will be answered directly by a duty

investigator from the AIC.

4. What the AIC needs to know — Notification

A person reporting an accident or serious incident should provide the following information:

Notification should not be delayed if all of the information is not available initially.

● Aircraft manufacturer/model.

● Aircraft registration.

● Name of the owner or operator.

● Number of flight crew and cabin crew.

● Names and qualifications of the flight crew.

● Number of passengers (The AIC will require the flight manifest giving the names and nationalities of all persons on board as soon as possible, but no later than 12 hours after the accident.

● Date and time of the accident / incident in UTC.

● Aircraft’s last departure point and its intended destination.

● Type of flight (passenger, cargo, survey, positioning etc).

+675 75500715

+675 75500703

Filing a CA005 within 3 working days does not

satisfy the legal requirement to notify CASA

with a minimum of delay and by the most

suitable and quickest means available.


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● Location of the accident with reference to some easily defined geographical point and latitude and longitude.

● Number of crew and passengers (or other persons not on board the aircraft) fatally or seriously injured.

● Description of the accident or serious incident and the extent of damage to the aircraft so far as is known.

● Details of any dangerous goods onboard.

● Confirmation that the CVR/FDR have been isolated. (Electrical power switched off)

The AIC would prefer have an early notification of something that later turns out not to require AIC action than to have a late notification of something that does require AIC investigation. Early notification will ensure appropriate and timely access to recorded data and information.

Following the initial notification, the AIC is likely to want additional information, including:

● Contact details, location and availability of the operating crew.

● Contact details of the operator’s safety manager and accountable manager.

● Passenger Manifest including contact details for each passenger.

● A copy of the complete flight documents including; navigation logs, load plans,

aircraft technical logs, NOTAMS and so on.

● ATC recorded data/information and logs.

Much of this information can be pre-identified and included in the aircraft

operator’s and service provider’s emergency planning checklist.

5. Preservation of evidence

Operator emergency planning should take account of the need to preserve critical

information and documents.

Following an accident or serious incident it is imperative that an operator swiftly

takes all necessary steps to secure the Flight Data Recorder (FDR) and Cockpit

Voice Recorder (CVR). Detailed information on preserving recorded data is

included in the paragraph entitled Flight Data and Cockpit Voice Recorders.

Additionally, the operator should impound (preserve from deletion and editing)

all records relating to that aircraft and its crew. This should include company

electronic records including emails, voicemail and safety databases. The originals

should remain protected, but accessible, throughout the course of any

investigation which, for the most complex cases, could take many months.


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6. The role of the AIC

The Accident Investigation Commission (AIC) is an independent organisation and

is completely separate from the Civil Aviation Safety Authority (CAA), Service

Providers, and the PNG judicial system. The Chief Executive Officer is directly

responsible to the AIC Board where the Board reports to the Minister for Civil

Aviation.

The AIC is responsible for the investigation of civil aircraft accidents and incidents

to aircraft of any State when the incident or accident occurs within PNG.

The AIC may also commence an investigation when the accident or incident

involves a foreign aircraft (being an accident that is required by the Convention

on International Civil Aviation to be investigated), or is at the interface of the civil

and military aviation systems.

The AIC also has the legislated power to investigate any aviation accident or

incident that involves any combination of military and non-military persons,

aircraft, aerodromes, aeronautical products or aviation related services.

The CAAct defines “military” as being with respect to any aircraft or facility, or an

aircraft or facility operated by the Defence Force or a visiting defence force.

The AIC’s objective is:

It is not the purpose of AIC investigations to apportion blame or liability.

At times the AIC will make findings and recommendations related to safety

concerns identified during the course of an accident or incident investigation,

that while not related to the root cause of the accident or incident, nevertheless

could contribute to an accident or incident in the future if not resolved.

To improve aviation safety by

determining the causes and

contributing factors of aircraft

accidents and incidents and

encouraging safety action and making

safety recommendations intended to

prevent recurrence.


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7. The AIC’s legal powers to investigate

Under current legislation, and in conformity with international conventions, the

AIC is obligated to operate in accordance with:

● Annex 13 to the Convention on International Civil Aviation.

● The Civil Aviation Act 2000 (as amended) (CAAct).

● The Commissions of Inquiry Act 1951 (as amended) Chapter 31.

● AIC Investigation Policy and Procedures Manual.

Note: These documents define the procedures to be followed in the investigation

of aircraft accidents and incidents and provide the powers for the Commission to

obtain evidence in any form and provide for its protection.

The CAAct specifies that for the purposes of carrying out its functions and duties

under the CAAct, the Commission shall have the same powers as are conferred

on a Commission of Inquiry by the Commissions of Inquiry Act (Chapter 31) and

all the provisions of that Act, shall apply accordingly. In addition, the Commission

shall have all such powers as may be conferred on it by the CAAct or by any other

Act, and as may be reasonably necessary or expedient to enable it to carry out its

functions.

Section 247 of the CAAct specifies the accidents and incidents to be investigated

by the Commission. Additionally, the Commission may decide to investigate any

incident where it considers that such an investigation may be expected to bring

a significant benefit to aviation safety.

When an accident occurs to an aircraft in PNG, the aircraft (including the

contents and parts thereof) are deemed to be in the custody of the Commission

for such period as the Commission considers necessary for the purposes of an

accident inquiry, and must not be removed or otherwise interfered with except

with the permission of the Chief Commissioner, the Deputy Chief Commissioner

or the Chief Executive.

It is the AIC’s policy to ensure that, as far as possible, its investigations do not

disrupt aircraft operations, however sometimes this is inevitable. The AIC

Investigator will endeavour to release any aircraft, documents or equipment as

quickly as possible, subject to the requirements of the investigation.

The CAAct grants legal powers to AIC Investigators to remove and retain all

relevant evidence, including aircraft wreckage, components, and documents, and

can have access to and inspect any place, building or aircraft for the purposes of

completing their enquiries. They have the authority to take recorded and/or

signed statements from anyone involved directly or indirectly with an accident or

incident.


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8. Legal powers of an AIC Investigator

The powers of an AIC Investigator which are most relevant when dealing with

aircraft operators are as follows:

• To have unhindered access to the site of the accident or incident as well as to the aircraft, its contents or its wreckage.

• To have immediate access to and use of the contents of the flight recorders and any other recordings.

• To have unhindered access to any relevant information or records held by the pilot, the owner, the operator, maintainer, the manufacturer of the aircraft, and the organisations responsible for civil aviation, air traffic services, and airports/aerodromes.

• To take statements from all such persons as the Investigator thinks fit and to require any such person to make and sign a declaration of the truth of their statement.

• To take such measures for the preservation of evidence as the Investigator considers appropriate.

When the AIC requires the production of evidence or to conduct an interview in

support of its investigation, a Form AIC_F018 will be issued to a specific person

responsible for providing the evidence or interview. The issuance of the AIC_F018

form while having strictly enforceable requirements on the recipient, also affords

protection in that the evidence or information provided may only be used for

investigation purposes under the CAAct. (See Appendix C)

9. The AIC response

Upon notification of an accident or incident occurring within the PNG, the AIC

will liaise with air traffic control, the aircraft and airport operators, police, and

emergency services as appropriate to ensure that evidence associated with the

occurrence is secured and to determine the level of AIC response.

The AIC Duty Investigator will inform the Investigations Manager who will notify

the CEO. The Duty Investigator will also notify the relevant investigators as soon

as possible, and schedule a time at the earliest convenience to meet and discuss

the notification details and to determine the type/level of response required.

The Investigations Manager will contact the CASA Executive Manager Safety

Regulations, informing him/her of the AIC’s intentions with regard to the

investigation of an occurrence, specifically if an investigation will be conducted.

If an occurrence is determined to be an accident or a serious incident, the CEO,

in consultation with the Investigations Manager, shall assess the magnitude of

the tasks and the scope of the investigation as soon as possible, so that an

appropriately qualified and experienced investigator can be appointed as the

Investigator in Charge (IIC).


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With approval from the CEO, the

investigation team will be selected and

activated, and appropriate resources and

expertise will be acquired for the

investigation. The IIC, in consultation with

the Investigations Manager will determine

the size of the investigation team and the

initial plan of action.

The AIC policy requires that at least one experienced investigator will be assigned

to an on-site investigation to ensure the required level of experience during the

on-site phase of the investigation. Office investigations will have the benefit of a

number of experienced investigators to assist during the investigation.

An investigator will be appointed by the IIC, (or the Investigations Manager if the

IIC has departed to go to the accident site), to contact organisations such as

CASA, the operator, maintenance organisations, and PNG ASL, as appropriate to

the known circumstances of the accident or incident, to ensure that evidence,

including documents and recorded data is secured as soon as possible.

The appointed investigator will provide the appropriate section(s) of the AIC

Investigation Checklist to these organisations as soon as possible, for them to

complete the relevant information while the on-site or office investigations

proceed.

The AIC Duty Investigator will coordinate the notification with other State

Investigation Authorities/Agencies, relevant PNG government agencies and other

industry organisations, such as search and rescue, police, etc, and ICAO in

accordance with ICAO Annex 13.

AIC may decide not to investigate

The AIC may decide that an occurrence does not require investigation by the AIC.

In accordance with the CAAct, the AIC will inform CASA when a notified accident

or incident is not being investigated by the AIC.

However, in these cases the AIC may still request a copy of an operator’s internal

investigation report, when it is complete. This allows the AIC to review its

decisions and helps to inform future decision making.


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10. The investigation process

Following completion of the initial

evidence gathering phase, the wreckage

or components of specific interest may

be removed to the AIC or other

appropriate facilities.

Evidence gathering will continue away

from the accident site as the

investigation progresses. This can take

some considerable time and may include activities such as detailed examination

of the wreckage, further interviewing of witnesses, research of specific issues,

interpretation of the recorded flight data, consultation with technical experts and

component testing at the manufacturer’s facilities or in specialist laboratories.

When the relevant facts have been determined this information will be analysed

in order to determine the cause(s) of the accident. The factual information, its

analysis and the conclusions of the investigation will be documented in the final

investigation report.

The report will endeavor to protect the anonymity of persons involved, but not

necessarily the organisations. Where appropriate, the report will contain

statements of Safety Action taken by individuals or organisations and/or Safety

Recommendations to address issues of safety concern identified during the course

of the investigation.

The investigation process may take many months depending on its nature and

complexity.

The AIC will issue a Preliminary Report within 30 days of the commencement of

the investigation. It will contain evidence that has been verified during that

period, and may contain statement(s) of Safety Action taken or proposed, and

Safety Recommendations.

The Preliminary Report will be published and becomes a public document.

A draft copy of the AIC’s Final Report will be sent to the flight crew, the operator,

CASA and the States of Registry, the Operator, and States of Design and

Manufacture of the airframe and powerplants and any other involved

organisation, seeking comment on the draft report. The State(s) of Manufacturer

will coordinate with the manufacturers to obtain their comment on the Draft

Report. If an involved party should seek to have the draft report amended, their

comment must be substantiated with evidence.

In accordance with ICAO Annex 13 Standards, there will be a 60-day period in

which to make any written representations on the contents of the draft report.


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Where possible the AIC aims to adopt an inclusive and collaborative approach

with other organisations participating in the investigation. This ensures a more

robust investigation and means there should be few surprises when the draft

report is circulated for comment.

A copy of the final report will be sent to those persons and organisations and to

ICAO prior to publication on the AIC web site at: www.aic.gov.pg

11. Safety Recommendations

A Safety Recommendation will be made as soon as possible after the AIC

determines that action is required in order to address safety issues identified

during the course of an investigation. In general, Safety Recommendations are

brought to the attention of the addressee in advance of being published. A Safety

Recommendation will be issued in writing, directly with the recipient normally by

e-mail if the AIC decides that the Safety Recommendation cannot wait for the

publication of the final report.

The AIC is not a regulatory authority and therefore, cannot enforce its

recommendations. However, in accordance with Annex 13, the AIC requests that

recipients of AIC Safety Recommendations will inform the AIC within 90 days of

the issuance of a Safety Recommendation, of safety action taken, or proposed, to

address the identified safety deficiency.

12. Safety actions

During an investigation it may become apparent that certain safety actions or

changes can improve the ongoing safety of an operation or the aviation system.

The development of company initiatives to address safety deficiencies will ensure

continued flight safety following an incident or accident. There is no requirement

for operators, service providers or manufacturers to wait for the AIC to make a

Safety Recommendation before making safety improvements. Such safety actions

will be reflected in the AIC’s reports.

13. Areas not within the scope of the investigation

If the AIC does not comment on an aspect of an organisation’s operation, it should

not be assumed that the AIC approves of, or condones, a particular operational

style or technique. Operators should not use an AIC investigation of one aspect

of their operation to demonstrate that another unrelated aspect is safe or

appropriate.



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14. International context

Most investigations have an international element. ICAO Annex 13 provides the

‘Standards and Recommended Practices’ to be used for the investigation of

aircraft accidents and serious incidents. These protocols, adopted in PNG

legislation, direct that an investigation into an aircraft accident or incident will

be initiated by the State of Occurrence.

The State of Manufacture of the aircraft or engines, the State of Design, the State

of Registry, and the State of the Operator are each entitled to nominate an

Accredited Representative to participate in the investigation. Other States which

provide expertise to the investigation or have a special interest by virtue of

fatalities or serious injuries to its citizens are also entitled to participate in the

investigation. Responsibility for the investigation of accidents occurring in

international waters falls to the State of Registry.

15. Participation in AIC investigations

In addition to those States entitled to participate in an investigation under the

provisions of ICAO Annex 13, the AIC may also invite participation from those

organisations that can provide the necessary technical assistance to the

investigation. These may include the operator, service provider, manufacturers of

the aircraft, systems and powerplants; the regulatory bodies; or other relevant

technical specialists. Representatives from PNG-based operators and service

providers may be appointed as Advisors reporting directly to the IIC.

Representatives from foreign operators will work in support of their State’s

Accredited Representative.

Section 242 of the CAAct provides for the appointment of Expert Assessors to

provide specialist expertise and advice to assist the AIC’s investigation.

16. Overseas investigations

Reporting

The initial response to an accident or serious incident, occurring to a PNG

registered aircraft being operated in another State, is the responsibility of the

accident investigation authority of the State of Occurrence. Pilots and Operators

must provide a notification of the occurrence in accordance with the local

procedures and laws in the State of Occurrence. The following ICAO website link

provides contact for many overseas accident investigation authorities:

http://www.icao.int/safety/aia

In addition, pilots, operators, and service providers are required to also inform

the CASA PNG and desirably the AIC with a minimum of delay and by the most

suitable and quickest means available, once the local reporting obligations in the

State of Occurrence have been met.

http://www.icao.int/safety/aia


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The AIC cannot assist unless it has been notified of the occurrence. The AIC will

be able to assist you in notifying the State of Occurrence if you have any difficulty

notifying that accident investigation authority of an accident or incident.

Participation

The AIC will participate in investigations of accidents that occur outside PNG

when the operator of the aircraft is based in PNG; and/or when the aircraft is

registered in PNG. In these cases the AIC will appoint an Accredited

Representative and may invite the operator to nominate an Advisor(s) to the PNG

Accredited Representative.

While the majority of investigations in ICAO signatory States follow the protocols

prescribed in Annex 13, the manner in which the investigation is conducted may

vary from State to State. In some countries, the legal system may require that a

separate judicial investigation takes place; this may take precedence over the

Annex 13 safety investigation.

17. The role of the Advisor

The role of the Advisor is to provide technical assistance to the IIC and/or the

Accredited Representative to whom they are affiliated, in order to assist in

developing a complete and accurate factual record. Where necessary the IIC will

provide guidance for Accredited Representatives and Advisors with respect to the

scope and requirements of the investigation. The Accredited Representative

reports to the IIC.

The AIC acknowledges that Advisors may also wish to represent the interests of

their organisation and while it is appropriate that they do so, the potential for a

conflict of interest may arise. Aircraft operators and manufacturers are

understandably eager for information, especially during the early stages of an

investigation, and it is important that they are kept informed and have timely

access to facts regarding the accident or incident that will facilitate prompt

preventative and / or corrective action.

However, in order not to jeopardise the investigation and to ensure that only

validated information is provided, the Advisor is not permitted to release any

information from the investigation to their organisation, to the media, or into the

public domain without prior approval from the IIC. Failure to observe this or to

act in a manner considered prejudicial to the investigation may result in

exclusion from the investigation.

The operator / manufacturer should be aware of the demands on the Advisors

and ensure that appropriate provisions and communications channels are

stipulated in their emergency planning documentation.


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Appendix D contains the AIC’s proforma Declaration of Conflict of Interest This

document, which must be signed by all parties joining the AIC’s investigation,

lists the permissions and obligations and requires the Party to declare known or

perceived conflict(s) of interest.

The following persons will not be permitted to participate in an AIC investigation

because of real and perceived conflict(s) of interest:

● Any person representing an organisation that has interests beyond the safety objective of the investigation.

● Any person occupying a legal position.

● Any person representing claimants or insurers.

18. Operator emergency planning

It may be appropriate for operators to identify in advance those staff who are

likely to be nominated as Advisors in the event of an accident. Key details such

as copies of their passports, vaccinations, accreditations etc., should be kept on

file to facilitate security/visa requirements and accident site access if

participating in an investigation.

The operator should provide advance notice of contact details for key safety

personnel within their organisation to the AIC by email to [email protected] and

update these as required. Often the AIC is informed of accidents or incidents by

third parties and it is important to be able to get immediate clarification from the

operator’s Safety Manager or equivalent.

By prior arrangement, an operator or service provider may notify the AIC of a

simulated accident scenario in the context of an emergency planning exercise.

Operators and service providers should notify the AIC Duty Investigator, in

advance, via the Duty Officer contact number.

Many operators have a provision in their emergency plans to deploy a relief

aircraft to accidents locations occurring overseas. It may be possible for the AIC

team to travel on the relief aircraft. Depending on the nature and location of the

accident, this may be the most practical means of travel and would allow briefing

and co-ordination between the AIC team and the operator’s Advisors.

Desirably this can be coordinated at the time of notification. However, the AIC

will not delay deployment to travel on a relief aircraft if more expedient means

are available.



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19. AIC interface with an operator or service provider during an

investigation

Access to operator’s staff

AIC Investigators will expect to contact the staff of the operator and/or service

provider following an accident or serious incident. This will include interviews

with the crew and may also involve maintainers, support staff and management.

Depending on the circumstances, these could take place near the location of the

occurrence, at the AIC HQ in Port Moresby, the premises of the operator or

service provider, or in any mutually convenient suitable location.

Operators and service providers need to consider the likely impact on their

operations and ensure that safety critical staff are fit to return to work. For shift

workers, the AIC may require a copy of the individual’s roster, either as part of

the investigation or simply to ensure that pre-work rest is not inadvertently

compromised. The AIC always reserves the right to talk with individuals without

reference to their employer.

Interviews

The sole purpose of an interview is to provide the AIC Investigator with a record

of what a witness saw or heard of the accident / incident, or knows of the events

leading up to it. The details they give, whether in a written statement or verbally,

will only be used by the AIC in its investigation.

Employees may not be accompanied by anyone who is there to represent the

interests of the company (for example a manager or company legal advisor). The

AIC’s obligation to maintain confidentiality over the contents of statements

obtained from witnesses means that it will normally exclude such persons from

the interview. However, interviewees may if they wish, have a colleague / friend

present for emotional support subject to AIC approval. Such persons are not

permitted to answer questions or make statements on behalf of the interviewee.

Access to documents

AIC Investigators may require access to various documents and records during

the course of an investigation. These may include, but are not limited to:

● operating manuals

● training records

● rosters

● maintenance records and procedures

● engineering drawings

● safety database records

● historic FDM data

● minutes of flight safety meetings

● SMS manuals

● audit reports

● ATC logs.


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Operators should take all necessary steps to make this information available

without delay upon request.

The AIC acknowledge that some information/data may be considered

proprietary/commercial-in-confidence. Such information will be for safety

investigation purposes and will not be made available to other commercial entities

participating in the investigation without permission from the originator.

Access to facilities

AIC Investigators may on occasion require access to maintenance areas, other

similarly equipped aircraft, flight crew training facilities, landside and airside

terminal facilities, flight crew briefing areas, aircraft flight decks and office

facilities.

For lengthy investigations the operator may also consider the provision of

appropriate hangar / office accommodation for the AIC team and on occasions

the AIC Investigators may need to observe a routine flight, simulator training

session or maintenance procedure being performed in order to assist in

understanding the operational context of the incident or accident.

Passenger questionnaire

Operators should be aware that it is important for the AIC to understand

passenger behaviour in accidents or serious incidents such as an emergency

evacuation. The AIC has a passenger questionnaire to enable investigators to

gain an understanding of the circumstances of the accident including the

evacuation from the aircraft following an accident.

Operators may assist the AIC to distribute the questionnaire to passengers

following an accident or relevant serious incident.

The AIC recommends that a copy of the AIC questionnaire should be included in

operators’ emergency planning documents.

The questionnaire is available on the AIC website www.aic.gov.pg.

20. Internal investigations conducted by operators and service providers

Operators and service providers are responsible for managing their ongoing safety

and operational risk and in so doing will conduct a parallel internal safety

investigation.

However, it is important that the AIC investigation or evidential chain is not

compromised. Actions as simple as taking a fuel sample, removing a component

or running a system test may inadvertently compromise evidence.

http://www/


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Note: In accordance with Section 246 of the CAAct:

“When an accident occurs to an aircraft in PNG, the aircraft (including

the contents thereof) shall be deemed to be in the custody of the

Commission (AIC) for such period as the Commission considers

necessary for the purposes of an accident inquiry, and shall not be

removed or otherwise interfered with except with the permission of the

Chief Commissioner, Deputy Chief Commissioner or the Chief

Executive.”

Exceptions apply for the extrication of persons, animals, and valuables which

also allows for the work of the Coroner and Police assisting the Coroner.

Until the aircraft or other system(s) or equipment are formally released back to

the operator or service provider, any work in support of operator and service

provider internal investigation must be approved in advance by the IIC.

Additionally, it is desirable that operators and Service Providers do not conduct

their own interviews of the flight crew, cabin crew or maintenance personnel, or

Air Traffic Controllers and Flight Service Officers before the AIC have interviewed

them.

Operators may be granted supervised access to physical evidence, such as the

aircraft/wreckage or components and will obviously have access to their own staff

and other resources such as Quick Access Recorder (QAR) data as part of an

internal investigation.

Operators will not be granted access to cockpit voice or image recorder data

(where fitted) or witness statements taken by the AIC.

21. Media relations

Media statements issued by the AIC will normally be

made by the Chief Commissioner or Chief Executive

Officer, but may be delegated to the Investigations

Manager. The IIC may be authorised on a case by case

basis to make a brief media statement at the accident

site.

Such briefing will be limited to evidence-based facts

that are approved by AIC management for public

release. This will normally be in order to give the TV

media a “talking head” with the backdrop of the

accident site to assist their factual coverage.

Operators, Service Providers, and manufacturers are

responsible for their own media relations following an accident or serious

incident, It is recognised that these organisations may wish to release press

statements, participate in press briefings or conduct TV / radio interviews.


23 | P a g e

The AIC has no control over such activities, but where possible the release of

information should be coordinated and prior agreement reached with the IIC or

AIC Management.

During an investigation the AIC may provide the Operator, Service Provider or

manufacturer with access to information to ensure the ongoing safety of their

operation. Public release of information provided in this way, without the explicit

approval of the IIC, is not permitted and may result in exclusion from the

investigation.

Note: The AIC is the only organisation that will issue statements on the status

and progress of an AIC investigation.

22. Passenger assistance

Aircraft Operators are responsible for ensuring they have an appropriate and

effective ‘Victim Assistance Plan’ that can be

implemented in the event of an accident. Plans should

include a point of contact for relatives and survivors

seeking assistance.

The AIC can, upon request, place the relevant contact

numbers / website details onto its own website to

facilitate contact with the operator following an

accident.

The AIC recommends that Operators familiarise

themselves with the requirements ICAO Circular 285-

AN/166, Guidance on assistance to aircraft accident victims and their families.

In 2005, family assistance was included in Annex 9

Facilitation.

The AIC will provide status and progress details of its

investigation normally at the time of issuing the

Preliminary Report; within 30 days of the date of the

accident.


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23. Flight Data and Cockpit Voice Recorders

The PNG Civil Aviation Rules Part 125, 135, and 136 provide the requirements for

the fitment of serviceable Flight Data and Cockpit Voice Recorders in specified

aeroplanes and helicopters. PNG CAR

Transition Rules CAR Part 20.105 refers to Part

125, Part 20.109 refers to Part 135, and Part

20.111 refers to Part 136. In addition, many

large air transport aircraft are also equipped

with a maintenance recorder (typically referred

to as a Quick Access Recorder (QAR)) that is

not crash protected.

The AIC aims to secure the flight recorders as quickly as possible following an accident or serious incident. The Pilots or operator must ensure that power supply to the recorders is interrupted as soon as possible after the accident or serious incident to ensure minimal loss of recorded information due to overwriting. Unless permission has been granted by the AIC, the flight recorders must not be removed from the aircraft and under no circumstances should an operator attempt to download the FDR or CVR.

The AIC will download the data from

the recorders “on-wing”, meaning

that the download is conducted with

the recorders left in the aircraft and

using the aircraft’s electrical power.

This process is used by the AIC

whenever possible to minimise

aircraft down time if the recorders

had to be taken to the AIC

Laboratory.

It is normal practice for the AIC to recover

both the FDR and CVR recorded information

and obtain the media disk / card from the

QAR.

In the event of a damaged recorder or

damaged or disrupted power supply from

the aircraft to the recorder, “on-wing” data

recovery may not be possible.


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In addition to the traditional sources of data such as flight recorders, there are

also likely to be other items of avionics which contain vital information such as

GPWS or TCAS etc. Air Traffic Control and Flight Service Unit recorded

information are examples of recorded information likely to be quarantined by the

AIC. The AIC may request that these items be impounded and the scope of such

a request will depend upon the circumstances of the occurrence.

Some aircraft are equipped to wirelessly transmit data to a ground station. This data could be from a QAR-type device, ACARS or similar system. Most operators in PNG use a tracking system such as the commercially available V2 Tracker, which is a very small GPS tracker capable of logging GPS data to a cloud server

at configurable intervals using hypertext transfer protocol (HTTP). The Global Positioning System (GPS) is a global navigation satellite system that provides geolocation and time information to a GPS receiver anywhere on or near the Earth where there is an unobstructed line of sight to four or more GPS satellites. Obstacles such as mountains and buildings block the relatively weak GPS signals. If an operator has received such data wirelessly from any of these systems from an aircraft involved in an accident or serious incident, they should ensure that the data is suitably secured and notify the AIC. If required, the AIC may provide a copy of the data from a FDR, QAR or other avionics at an early stage to the operator, Accredited Representative for use by their Advisor which would include the aircraft manufacturer.

Note: This does not apply to the CVR, the recordings of which are protected from disclosure by the AIC under PNG legislation and are classified as restricted information in accordance with ICAO Annex 13. Any data provided shall be treated as confidential by the operator, Accredited Representative and Advisers and must not be distributed further without the express written consent of the AIC.

Preservation of flight recordings

Operators and PNG Air Services Limited must have robust procedures in place

that minimise the loss of information from the FDR and CVR, and ATS recorder

information respectively following an accident or serious incident.

The operator must advise the AIC immediately if access to the aircraft, by

personnel suitably qualified to secure the FDR and CVR recordings, is prevented

by any other agency prior to the arrival of the AIC.

The FDR will typically stop recording when the aircraft engines have been shut

down. However, for many aircraft, the CVR will continue to operate whenever the

aircraft’s electrical system is powered.

https://en.wikipedia.org/wiki/Satellite_navigation

https://en.wikipedia.org/wiki/Geolocation

https://en.wikipedia.org/wiki/Time_transfer

https://en.wikipedia.org/wiki/GPS_receiver


26 | P a g e

Because of its relatively short recording duration of either the last 30 or 120

minutes (dependent upon model), it is vital to remove electrical power from the

CVR to avoid relevant parts of its recording being overwritten.

If the flight recorder circuit breakers have been pulled (confirmation that this has

been done is usually one of the first requests made by the AIC upon being notified

of an occurrence), it is also important to placard the circuit breakers “DO NOT

ACTIVATE” and also state that action in the aircraft’s Technical Log so that any

follow-up maintenance activity does not inadvertently reinstate the circuit

breakers and thus reactivate the CVR.

On some aircraft types, the flight recorder circuit breakers are not located in the

cockpit. Procedures should reflect this and detail how the surviving flight crew

should prevent the recordings being overwritten, such as electrically powering

down the aircraft until circuit breakers can be accessed by maintenance staff.

Operators should ensure that these procedures can be enforced across their

network, including at destinations where line maintenance activities may be

delegated to third party providers.

FDR documentation requirements

The FDR records binary data which needs to be decoded. Using a ground replay

system, the binary data can be converted to engineering units (knots, feet etc.)

by referencing a detailed document specific to the aircraft installation. The

generic name for this document is the Data Frame Layout (DFL).

PNG legislation requires an operator to keep the DFL documentation and CASA

PNG requires operators to demonstrate that they hold a copy of the DFL

documentation at the time of application for a Certificate of Airworthiness.

Operators are also required by CASA PNG to make the DFL available to support

the continued airworthiness of an aircraft, in particular the annual readout of

the FDR, and to support any accident or serious incident investigation carried

out by the AIC.

The AIC has built a database of DFL information for most aircraft in the PNG

fleet, but in the event that a specific aircraft’s DFL is not in the AIC database, one

of the first documents to be requested by the AIC Flight Recorder Investigator will

be the DFL for the aircraft. For aircraft equipped with a QAR, the AIC will also

seek to obtain DFL information from the operator.


27 | P a g e

Return of recorders

If the data download has not been able to be accomplished “on wing”, the AIC will

take all necessary and reasonable steps to return the flight recorders (or other

avionics) expeditiously. However, in some cases an aircraft may be released back

to the operator by the AIC before the flight recorders are ready to be released.

Also, if the recorders were damaged during the accident they will not be able to

be used in an aircraft before repair action, which is the responsibility of the

Operator. Operators are encouraged to have appropriate spares to cover such

contingencies.

Additionally, Operators should be aware that because the recorders have been

removed from an aircraft they will require a serviceability release certificate from

an approved avionics maintenance facility before they may be reinstalled. The

AIC cannot provide such a release certificate.

CASA documentation

The PNG Civil Aviation Rules define the requirements for routine readouts as well

as providing other useful advice on the subject of flight recorders.

24. Police and judicial investigations

The AIC will normally be the lead agency investigating aircraft accidents and

incidents in PNG. However, following a fatal accident it is highly likely that the

police will assist the Coroner. The AIC will not impede the Police and Coroner’s

work to recover the bodies of victims, but will ask the Police and Coroner to

document their removal and any post-accident disruption of the wreckage to

effect the removal.

The Coroner’s investigation will be separate from the AIC investigation. The AIC

will not provide the police or any third party with copies of witness statements or

cockpit voice or image recordings. However, the AIC can obtain Police witness

statements for any specific investigation.

Upon application to a Court, a Magistrate may decide that it is in the public

interest to release this information for certain purposes. In such applications the

AIC will remind the court that if such information is made public it may in the

future no longer be openly disclosed to investigators and that lack of access to

such information would impede the investigation process and seriously affect

flight safety.

Operators therefore need to be aware that there may be several separate

investigations proceeding at the same time but with different rules and objectives.

To ensure the separation of the AIC’s no-blame safety investigation from any

judicial or administrative process that would apportion blame and/or liability,

this may unavoidably result in operator’s staff being interviewed on multiple

occasions by different organisations under different procedures.


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25. Civil Aviation Regulator

The Civil Aviation Safety Authority of PNG (CASA) regulates commercial aviation

within the PNG through the Civil Aviation Rules. The AIC maintains

communication links with CASA and has a Memorandum of Understanding on

cooperation with CASA. The MOU takes account of the distinctly separate

investigation requirements of both organisations, while working to the same goal

of aviation safety.

The AIC may invite CASA to send an Advisor to participate in an AIC investigation.

In doing so the AIC must be satisfied that no conflict of interest will arise from

the appointment of the CASA Advisor and will place the Advisor under specific

conditions of confidence. The Advisor will not be permitted access to cockpit voice

or image recorder data.

CASA is obligated to provide the AIC with information to support the

investigation. This may include, but is not limited to, certification data,

occurrence reporting database information, personal licensing information,

audit/surveillance reports. The AIC will protect this data in accordance with the

relevant legislation.

During an investigation the AIC may need to provide CASA with pertinent factual

information that is not classified as restricted information to allow CASA to fulfil

its safety functions. Cockpit voice and image recordings are not released. Should

CASA require data or information that is restricted information, it must obtain it

from their own investigative sources separate from the AIC.

26. Accident site safety

There are numerous hazards at aircraft accident sites and the safety of personnel

working on such sites is paramount. Those involved in the examination,

documentation and recovery of aircraft wreckage may be exposed to risks from

hazards such as dangerous cargo, flammable or toxic materials and vapours,

sharp or heavy objects, pressurised equipment, biological hazards, airborne

hazards, adverse terrain and adverse climatic conditions.

In general, responsibility for the overall safety

on site will reside with the AIC. However, when

other agencies such as the Police, Fire Services,

Airport Operator etc. are present the AIC’s IIC

will consult with those experts. The IIC and /

or a designated AIC site safety co-ordinator will

be responsible for conducting a risk

assessment of the accident site to identify

possible hazards and determine the level of

risk. Based on the nature and extent of the identified hazards the AIC will employ

appropriate control measures and provide a briefing for all persons working on

the site.


29 | P a g e

However, this does not detract from each organisation’s own obligations towards

its personnel who are working on accident sites. As such, it is essential that

representatives from the Operator, Service Provider, Accredited Representative

and Advisers who may be required to participate in such on-si te investigations

are suitably trained and equipped to deal with accident site hazards. These

elements should be fundamental considerations in an operator’s emergency

planning.

The AIC will restrict access to hazardous accident sites. Only supervised access

will be permitted unless the personnel seeking access can show evidence of

having undergone site hazard and bloodborne pathegon awareness training. The

AIC conducts this training on a needs basis at its Port Moresby Training Room.

Operators are required to inform the AIC at the earliest possible opportunity

following an accident of any dangerous goods or hazardous cargo known to be on

board an aircraft involved in an accident. In addition, some aircraft systems

represent specific hazards on an accident site, particularly stored pressure

vessels such as oxygen bottles, hydraulic accumulators etc. This information is

often provided by aircraft manufacturers on a diagram specifically aimed at

advising airport fire services of particular aircraft hazards.

It is recommended that operators have this information readily available and

provide it to the AIC at the earliest opportunity following notification of an

accident or serious incident.

27. Recovery of wreckage

Recovery of the wreckage for ongoing accident investigation purposes will

normally be co-ordinated by the AIC. On occasions it may be necessary to enlist

assistance from other organisations such as the PNG Defence Force, specialist

aircraft recovery contractors, or the aircraft operator. The nature of the recovery

operation may vary greatly depending on the

size of the aircraft, the location of the accident

(on-airport or off-airport) and the degree of

disruption to the aircraft.

Where assistance is provided by the operator

in the form of personnel, equipment,

resources or hangar facilities, the aircraft or

wreckage remains in the custody of the AIC

and access to it will be strictly by permission

of the IIC. This is necessary to avoid any

interventions which may unintentionally

destroy evidence.


30 | P a g e

Where an aircraft is deemed by the insurer or operator to be salvageable, an

operator may wish to conduct the recovery operation with appropriately skilled

personnel to minimise further secondary damage. Such steps must not be taken

without prior agreement of the IIC, and the AIC will continue to observe the

process to ensure the preservation of evidence.

Components and flight recorders removed by the AIC from otherwise serviceable

aircraft will be retained as long as necessary for the purposes of the investigation.

While the AIC will endeavour to return these as soon as possible, operators

should be aware of this and make appropriate arrangements to replace them if

the aircraft is to be returned to service before completion of the investigation.

The legislation provides for the testing of aircraft systems and components during

an investigation, even to the point of destruction. While this is avoided whenever

possible, nevertheless it remains an option in the investigation process.

Wreckage not required for AIC examination, or if the examination has been

completed by the AIC at the accident site and the items are no longer required by

the AIC will be returned to the owner at the accident site. The aircraft is then the

responsibility of the owner, the operating company or the insurers. Personal

effects recovered from aircraft wreckage if not able to be given to the owner at the

site, will be handed to the police for safe custody. In other cases, this process will

be coordinated with the police, airport owner/operator and aircraft operator as

appropriate.

In all cases, liabilities and restoration work arising from the pollution or damage

to land and associated vegetation, water course, airport facilities, buildings,

utilities etc., caused by an aircraft accident will be the responsibility of the

operator through their insurers.

28. Wreckage recovery from the sea

Locating aircraft wreckage at sea and

its subsequent recovery from the sea

bed can be a very lengthy and

expensive operation with costs varying

depending on the size of the aircraft,

the depth of water, the location, the

weather and sea conditions etc.

The AIC will work with other agencies

including the National Maritime Safety Authority (MSA), the PNG Defence Force

to source appropriate specialist equipment for locating submerged wreckage. For

large scale sea-bed searches organisations such as commercial salvage operators

that have dedicated search and recovery capabilities may have to be contracted.


31 | P a g e

The AIC will generally seek to recover submerged aircraft wreckage in PNG waters

when it is considered necessary for the investigation, in order to establish the

cause(s) and contributing factors of an accident and when it is practical to do so.

However, in some circumstances the AIC will contact the aircraft operator’s

insurers and the State of Registry with a view to seeking an agreement for sharing

the costs of the recovery.

The AIC will make it clear to the operator of an aircraft that has crashed in or

near PNG waters and sunk that the AIC will monitor the salvage inside PNG

Territorial waters and when recovered the wreckage will be in the custody of the

AIC unless otherwise released to the owner by the AIC. Outside PNG Territorial

waters the responsibility rests with

the State of Registration, although

for accidents near PNG territory,

the AIC would assist. Operators

are strongly discouraged from

taking unilateral action, though

both the operator and the

manufacturer may send an

observer on board the recovery

vessel if there is space and

accommodation. This is seen as prudent since the manufacturer’s representative

particularly can be a ready source of aircraft type information to assist the AIC.

If the aircraft has remained afloat, the operator may wish to salvage their property

with a view to refurbishment, in which case the AIC will render assistance as

appropriate and provide advice to ensure the preservation of evidence for its

investigation.

In some cases, the AIC may seek to recover only the Flight Data and Cockpit Voice

Recorders and relevant parts of the aircraft wreckage. This may occur when

recovery of all of the aircraft wreckage is impractical. It will then be the

responsibility of the aircraft owner or the aircraft’s insurers to effect a recovery if

it is deemed appropriate for their purposes or if the wreckage poses a continual

hazard. In such a case the NMSA must be informed in case it poses an ongoing

threat to shipping.

Recovery of aircraft wreckage from international or oceanic waters brings an

additional level of complexity.


32 | P a g e

A regional example is the AdamAir

Boeing 737 that crashed into the

ocean off Sulawesi. The aircraft was

not recovered but the flight recorders

were located on the seabed at a depth

of more than 2,000 metres and were

recovered. The cost of the recovery of

the flight recorders was in excess of

USD 4.6m shared by the Indonesian

Government and the Operator.

Another recent example was Air France Flight 447, that disappeared into the

Atlantic Ocean while en-route from Rio de Janeiro to Paris. It took four separate

search missions and almost two years to locate the aircraft wreckage on the ocean

floor following its disappearance.

Recovery of the flight recorders and wreckage from water almost 4,000 metres

deep took a further eight weeks. The search and recovery operations amounted

to many millions of US dollars and cost sharing was unavoidable.


33 | P a g e

Appendix A: Extracts from ICAO Annex 13 to the Convention on International Civil Aviation

Some of the following extracts from ICAO Annex 13, Eleventh Edition are referenced in the PNG Civil Aviation Act 2000 (as amended)

Definitions

Accident. An occurrence associated with the operation of an aircraft which, in

the case of a manned aircraft, takes place between the time any person boards

the aircraft with the intention of flight until such time as all such persons have

disembarked, or in the case of an unmanned aircraft, takes place between the

time the aircraft is ready to move with the purpose of flight until such time as it

comes to rest at the end of the flight and the primary propulsion system is shut

down, in which:

a) a person is fatally or seriously injured as a result of:

— being in the aircraft, or

— direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or

— direct exposure to jet blast,

except when the injuries are from natural causes, self-inflicted or inflicted by

other persons, or when the injuries are to stowaways hiding outside the areas

normally available to the passengers and crew; or

b) the aircraft sustains damage or structural failure which:

— adversely affects the structural strength, performance or flight characteristics of the aircraft, and

— would normally require major repair or replacement of the affected component,

except for engine failure or damage, when the damage is limited to a single engine (including its cowlings or accessories), to propellers, wing tips, antennas, probes, vanes, tires, brakes, wheels, fairings, panels, landing gear doors, windscreens, the aircraft skin (such as small dents or puncture holes), or for minor damages to main rotor blades, tail rotor blades, landing gear, and those resulting from hail

or bird strike (including holes in the radome); or

c) the aircraft is missing or is completely inaccessible.

Note 1 — For statistical uniformity only, an injury resulting in death within thirty days of the date of the accident is classified, by ICAO, as a fatal injury.

Note 2 — An aircraft is considered to be missing when the official search has been terminated and the wreckage has not been located.


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Serious injury. An injury which is sustained by a person in an accident and which:

a) requires hospitalization for more than 48 hours, commencing within seven days from the date the injury was received; or

b) results in a fracture of any bone (except simple fractures of fingers, toes or nose); or

c) involves lacerations which cause severe hemorrhage, nerve, muscle or tendon damage; or

d) involves injury to any internal organ; or

e) involves second or third-degree burns, or any burns affecting more than 5 per

cent of the body surface; or

f) involves verified exposure to infectious substances or injurious radiation.

Incident. An occurrence, other than an accident, associated with the operation

of an aircraft which affects or could affect the safety of operation.

Causes. Actions, omissions, events, conditions, or a combination thereof, which

led to the accident or incident. The identification of causes does not imply the

assignment of fault or the determination of administrative, civil or criminal

liability.

Contributing factors. Actions, omissions, events, conditions, or a combination

thereof, which, if eliminated, avoided or absent, would have reduced the

probability of the accident or incident occurring, or mitigated the severity of the

consequences of the accident or incident. The identification of contributing

factors does not imply the assignment of fault or the determination of

administrative, civil or criminal liability.

Safety recommendation. A proposal of an accident investigation authority based on information derived from an investigation, made with the intention of preventing accidents or incidents and which in no case has the purpose of creating a presumption of blame or liability for an accident or incident. In addition to safety recommendations arising from accident and incident investigations, safety recommendations may result from diverse sources, including safety studies.

Serious incident. An incident involving circumstances indicating that there was

a high probability of an accident and associated with the operation of an aircraft

which, in the case of a manned aircraft, takes place between the time any person

boards the aircraft with the intention of flight until such time as all such persons

have disembarked, or in the case of an unmanned aircraft, takes place between

the time the aircraft is ready to move with the purpose of flight until such time

as it comes to rest at the end of the flight and the primary propulsion system is

shut down.

Note 1 — The difference between an accident and a serious incident lies only in the result.


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List of examples of serious incidents3

The incidents listed are typical examples of incidents that are likely to be serious incidents. The list is not exhaustive and only serves as guidance to the definition of serious incident.

• Near collisions requiring an avoidance manoeuvre to avoid a collision or an unsafe situation or when an avoidance action would have been appropriate.

• Collisions not classified as accidents.

• Controlled flight into terrain only marginally avoided.

• Aborted take-offs on a closed or engaged runway, on a taxiway or unassigned

runway.

• Take-offs from a closed or engaged runway, from a taxiway or unassigned runway.

• Landings or attempted landings on a closed or engaged runway, on a taxiway

or unassigned runway.

• Gross failures to achieve predicted performance during take-off or initial climb.

• Fires and/or smoke in the cockpit, in the passenger compartment, in cargo compartments or engine fires, even though such fires were extinguished by the use of extinguishing agents.

• Events requiring the emergency use of oxygen by the flight crew.

• Aircraft structural failures or engine disintegrations, including uncontained turbine engine failures, not classified as an accident.

• Multiple malfunctions of one or more aircraft systems seriously affecting the operation of the aircraft. Flight crew incapacitation in flight.

• Fuel quantity level or distribution situations requiring the declaration of an emergency by the pilot, such as insufficient fuel, fuel exhaustion, fuel starvation, or inability to use all usable fuel on board.

• Runway incursions classified with severity A. The Manual on the Prevention of Runway Incursions (Doc 9870) contains information on the severity classifications.

• Take-off or landing incidents. Incidents such as under-shooting, overrunning or running off the side of runways.

• System failures, weather phenomena, operations outside the approved flight envelope or other occurrences which caused or could have caused difficulties controlling the aircraft.

• Failures of more than one system in a redundancy system mandatory for flight guidance and navigation.

• The unintentional or, as an emergency measure, the intentional release of a slung load or any other load carried external to the aircraft.

Note: Reference to taxiways excludes authorised operations by helicopters.

3 ICAO Annex 13 Attachment C


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Appendix B: Roles of the investigation team members

The Investigations Manager has oversight responsibility for all investigations and related activities and is responsible to the CEO for the quality and timeliness of the investigation. Public statements about the status of the investigation that are not handled by the Board or CEO are normally delegated to and made by the Investigations Manager. The Investigations Manager reports to the Chief Executive Officer, who in turn reports to the AIC Board.

The Investigator-in-Charge (IIC), reports to the Investigations Manager. He/she will manage the operations of a specific investigation and coordinate investigative activities between the various investigators/teams assigned to the investigation. The IIC, assisted by the Investigations Manager, will be the focal point for Accredited Representatives from other States and for Advisors. The IIC will prepare all draft reports for review by the Investigations Manager.

The Operations Investigator, normally a pilot, will if possible, interview the pilots, cabin crew, passengers and other relevant witnesses with a view to determining the sequence of events that led to the accident or serious incident. They examine for example, flying procedures and techniques; human factors; aircraft performance; weather; airports; air traffic control and witness information.

The Engineering Investigator, is responsible for the examination of the aircraft or the wreckage. They will photograph and record all the evidence from the accident site and later examine the aircraft technical records, the aircraft design; airworthiness; systems; engines; structure; failure and fault analysis; maintenance procedures, records and documentation etc. They will also liaise closely with the maintenance organisation. They may arrange for the aircraft wreckage, components and other relevant material evidence to be removed and transported to the AIC Office in Port Moresby, or some other secure area, where they can carry out further examination and testing.

The Flight Recorder Investigator will download data/information “on wing” if the recorders are not damaged and power supply from the aircraft is available. If not they remove the FDR and CVR from the aircraft for replay and analysis at the AIC Laboratory in Port Moresby. They will also examine other sources of recorded information. Information from the CVR is confidential to the investigation team and is never released. The crew, however, are encouraged to visit the AIC, where possible, to listen to the recording. General flight parameters such as airspeed, altitude and heading as well as control inputs and detailed system data are recorded on the FDR. This information may be supplied to the operator and aircraft manufacturer to assist in the investigation.

The Air Traffic Management Investigator will obtain ATS recorded information and transcribe air traffic services communications and analyses ATS log entries and ATS manuals and other relevant documents. He/she assists the Operations Investigator and the IIC investigating airport issues and with transcribing interview records and provides ATS analysis assistance.


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Appendix C: AIC_F018 Formal Request for Interview or Production of

Evidence


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Appendix D: AIC_F044 Declaration of Conflict of Interest


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NOTES

TO REPORT AN AIRCRAFT ACCIDENT or INCIDENT

Telephone the

Civil Aviation Safety Authority of PNG (CASA)

+675 302 7528 (21:30 – 06:00 UTC) +675 7698 0239 (06:00 – 21:30 UTC) +675 7031 4167 (06:00 – 21:30 UTC)

and the

PNG Accident Investigation Commission (AIC)

+675 323 2911 or +675 7550 0715 (06:06 - 21:45 UTC) Duty Investigator +675 323 2184 or +675 7550 0703 (06:06 - 21:45 UTC) Duty Investigator

GENERAL ENQUIRIES

PNG Accident Investigation Commission

Level 1, NAQIA Haus, Portion 81, Moera Tobo Rd, 6 Mile, National Capital District, PNG

PO Box 1709, BOROKO, National Capital District, PNG

Tel: +675 323 2911,

Fax: +675 323 2139,

E-mail: [email protected]

Website: www.aic.gov.pg



Documents

AIRCRAFT ACCIDENTS and INCIDENTS for... · the whole of the investigation into a major aircraft accident involving a ATR 72-500 aircraft at Port Vila, Vanuatu, in accordance with